National Center for Complementary and Alternative Medicine 2010

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					            National Center for Complementary and Alternative Medicine
                              2010-2015 Strategic Plan
                              Stakeholder Commentary
                                       By the
                  American Association of Naturopathic Physicians
                                 November 19, 2009


While conventional medicine‘s focus on treatment of disease has produced many
benefits, especially in acute and life-threatening conditions, its effectiveness for the
treatment of chronic disease or the promotion of health is limited. This limitation has
been a major cause of the out-of-control healthcare costs plaguing the nation.

There is, at present, a severe shortage of primary care physicians. A number of proposals
have been put forth as to how to fill that shortage and many of these are aimed at
increasing the number of medical students going in to primary care. However, there are
also a number of proposals to utilize the skills of other licensed healthcare practitioners to
expand access to patient-centered primary care in both federally funded and private
health care offerings—e.g., naturopathic physicians (NDs). What is now required is the
development and funding of outcomes-based research initiatives that demonstrate how
this care will enable the transformation of our disease-based system into one that is
rooted in sustainable health and wellness.

Naturopathic medicine is a system and philosophy of medicine that has been in use for
over 100 years. The American Association of Naturopathic Physicians (AANP)
represents licensed naturopathic physicians who are trained at fully accredited four-year,
residential medical programs. Graduates of our medical schools serve as primary care
physicians and have the same training in the basic and clinical sciences as conventional
medical doctors. In addition, NDs receive training in a variety of core treatment methods
including nutrition, botanical medicine, homeopathy, pharmacology, physical therapy,
and minor office surgical procedures. Some licensed naturopathic physicians are also
trained in traditional Chinese medicine, acupuncture and Ayurvedic medicine as well as
clinical specialties such as natural childbirth. Therefore, naturopathic medicine and NDs
provide the ideal laboratory to test a complement to the present primary-care-deficient
model of health care.
The Changing Role of Natural Medicine

As NCCAM evaluates its existing strategic direction for the next five years, it is essential
to recognize the dramatically changing landscape of the ―complementary and alternative‖
(CAM) world. Terminology and practices are shifting daily, opening new doors and
breaking down barriers. Practitioners of natural medicine and alternative therapies
continue to organize themselves professionally and academically. In addition, there is
growing acknowledgement and acceptance of these practices in the more conventional
environments, as is evidenced by the utilization of terminology that includes integrative
medicine and integrative health – terminology that is utilized by conventional and non-
conventional providers alike.

How the research community and NCCAM itself respond to integration of ‗alternative‘
and ‗conventional‘ medicines stands to dramatically impact the development of a
sustainable health care system. Integration holds the potential for a newly defined
worldview of wellness, increasing acceptance of treating the whole person and
systemically valuing true prevention and the body‘s ability to heal at a time when chronic
disease promises to cripple our financial future. Yet it is essential to note, research
initiatives that are successful in demonstrating effective integration of conventional and
natural medicine will require continued commitment to educational and testing standards
by the professions, and established research protocols that recognize the underlying
principles associated with each profession. The Commonwealth Working Group on
Traditional Complementary Health Systems at the University of Oxford, in a study of
developing countries across Asia, India and Africa, found that successful integration of
CAM and conventional medical systems requires the professions to first self-regulate
standards of practice and training (Bodeker, 2001). AANP, along with many of the other
CAM professional organizations, stand committed to establishing standards on par with
that of their allopathic counterparts. In addition, the study concluded that the central
regulation of natural products through good manufacturing practices and sound research
is essential to effective integration efforts (Bodeker). Viable pathways towards effective
integration of ‗alternative‘ care into the conventional paradigm should be viewed with
careful consideration. Why? In China, it was demonstrated that domination of
conventional medicine can result in the dilution of traditional philosophies and practices,
compromising the quality of education (Bodeker, 2001). Today, existing research
initiatives fail to incorporate the relevance of philosophy to both the practitioner and the
health care outcomes of the patient – ergo, the relationship of the naturopathic physician
to his or her patient is undervalued in the current effectiveness evaluation scales.

We strongly encourage thoughtful development of research paradigms that are 1)
outcomes-based, 2) incorporate the importance of philosophy and education, 3) evaluate
the provider/patient relationship, and 4) serve to redefine and quantify the standard
interpretation of health and wellness programs.

NCCAM Capacity to Conduct Effective and Representative Research
The Center has an enormous opportunity over the course of the next five years to meet its
stated mission relating to 1) the composition of the Advisory Council, 2) availing itself of
―appropriate expertise‖ from the CAM scientific realm, and 3) the call to include
accredited and licensed professions in the evaluation of alternative and complementary
treatment. In the naturopathic medical field alone, the number of qualified researchers,
the research programs at accredited institutions and the number of naturopathic
physicians practicing in integrative environments has grown dramatically. NCCAM, and
the federal agencies that are best suited to partner in CAM research initiatives, should
avail themselves of the numerous high-quality, cost-effective medical practice patterns of
highly skilled physicians and practitioners for the purpose of conducting quality,
outcomes-based research. Expanding NCCAM‘s worldview of developing research
initiatives and private sector offerings, could significantly impact the types of projects
undertaken across federal agencies, and substantially add to the growing body of research
on outcomes and effectiveness of naturopathic treatment.

In April 2009, the AANP submitted testimony to the Federal Coordinating Council for
Comparative Effectiveness Research on its commitment to outcomes research, the
determination of best practices and the need to fund evaluation of alternative systems of
healthcare. We specifically proposed funding of health information technology and
electronic medical records in a practice-based research network (PBRN) containing both
conventional and naturopathic medical practices to compare ―real world‖ effectiveness
and cost-effectiveness for type 2 diabetes. Creation of this PBRN has been initiated, and
will include collaboration with other private and public sector research and academic
institutions. The proposal calls first for retrospective and pilot prospective studies to test
the feasibility of protocols based on an informatics approach to naturopathic medicine
outcomes research and to characterize the populations before going on to more definitive
study. If there are positive results with comprehensive treatment, the treatment and the
outcomes data can be examined for factors associated with improvement.

Comparative Effectiveness Research: A Case Study

The initial proposal is for a study on type 2 diabetes (T2D). T2D is epidemic and often
inadequately controlled (only 37% in adequate glycemic control) by approved treatments.
Nearly half (47.9%) of US diabetes patients also use complementary and alternative
medicine (Garrow & Egede 2006; Yeh, Eisenberg, Davis & Phillips, 2002). The Diabetes
Prevention Program (DPP) conclusively demonstrated that diet and lifestyle changes
could prevent diabetes more effectively in a susceptible population than metformin (58%
reduction in incidence versus 31%). The DPP lifestyle intervention used lifestyle coaches
and a focus on weight loss and exercise, and although it proved less expensive per case of
diabetes prevented than pharmacological management alone, it still presents a substantial
cost to implement. ND practices will be used to test modifications to this model that
include a primary care setting allowing diabetes prevention to be incorporated into
patients‘ overall focus on health. It may be even more effective, e.g., through the
inclusion of nutritional supplementation (Bartlett & Eperjesi, 2008; Farvid, Jalali, Siassi
& Hosseini, 2005; Bonnefont-Rousselot, 2004)), and potentially, more cost-effective.
Diabetes is paradigmatic of endemic chronic diseases for which NDs have specific well
rationalized treatment protocols of which the elements, individually, show promise but
have not been tested in combined practice. This PBRN proposal can be used to test
components of primary care that can also be incorporated into conventional practice.

Diabetes is an important chronic condition but it is only one of many conditions toward
which the informatics-based research infrastructure that we propose can be targeted.
NCCAM funding of such systems could enable the determination of the best approaches
to general primary care/family practice, pain, and other chronic disease conditions.

Opportunities and Obstacles for Outcomes-Based Research

NCCAM‘s original mandate reads ―the Director of the Centers shall identify and evaluate
alternative and complementary medical treatment, diagnostic and prevention modalities
in each of the disciplines and systems which the Center is concerned, including each
discipline and system in which accreditation, national certification, or a State license is
available.‖ The AANP would assert that NCCAM has not fully availed itself of the
unique opportunities associated with cost-effectiveness research across the naturopathic
profession. Federal funding for health research in many agencies remains restricted to
those professions identified in the Social Security Act, overlooking the other primary care
providers licensed in many states across the country. And, despite the fact that
corporations are experiencing enormous success in the implementation of even the most
basic wellness programs, Congress and many policy makers remain unconvinced and
unable to attribute savings for these programs. Thus, federal law and the current health
insurance reform efforts are not able to avail themselves of programs that stand at the
forefront of reducing the prevalence of chronic disease, and transformation from a
disease-based system.

Cost-effective, Quality Outcomes

One such example of how naturopathic medicine is transforming outcomes in the private
sector exists in Vermont with the ―Jump Start To Better Health‖ program for employees
of a statewide association. The program uses an approach to improving employee
wellness that includes fitness and weight loss challenges, a monthly newsletter, on-site
flu immunization clinics, on-site health awareness screenings, a smoking cessation
program, online wellness center, the FirstLine Therapy Therapeutic Lifestyle Change
program, and a comprehensive incentive program with $10,000.00 in cash prizes.

The ―Jump Start To Better Health‖ program was designed by a naturopathic physician,
Dr. Bernie Noe. It has dramatically improved the health of association members, and has
helped cut healthcare costs. In the first two years of the program, the occurrence of high
blood pressure decreased by 49 percent, while the occurrence of high cholesterol
decreased by 26 percent. The occurrence of smoking, physical inactivity, and multiple
risk factors for cardiovascular disease, all decreased by more than ten percent. The
Association estimates that during the program‘s first two years, it saved an average of
$8.20 in health care costs for every $1.00 invested in the program. This translates into an
overall savings of $1,421,000 in direct and indirect health costs during that time period.

Another powerful example of the direct correlation between patient access to a wide
range of healthcare provider options and more efficient, cost-effective healthcare has
been demonstrated in a study funded by NCCAM. In the study, Patricia Herman, ND,
compared conventional and naturopathic lower back pain treatments. Dr. Herman found
that the naturopathic model of care was less costly than conventional treatment, when
accounting for absenteeism. The naturopathic model also had the added benefits of
improving health outcomes and lowering other medical costs.

A second study by Dr. Herman, also funded by NCCAM, found that integrative care can
reduce reliance on conventional drugs in a study of patients with eating disorders. A
comparison of patients treated conventionally, and those treated with added integrative
therapies including dietary supplements, acupuncture and massage showed that patients
receiving integrated treatments generally had decreased symptoms and reliance on
conventional medications. Two common conditions in eating disorder patients,
constipation and sleep disorder, reduced significantly. In fact, reliance on sleep
medications was reduced from 55 percent to 11 percent in the integrated patient group.
Naturopathic therapies, in place of or in conjunction with conventional care, can provide
increased health outcomes at reduced costs. NCCAM funding of studies such as these is
evidence that utilization of naturopathic expertise can greatly ease the burden on our
nation‘s healthcare system.


In fall, 2009, the Department of Labor issued a custom report defining the role of a
naturopathic physician to read:

       ―Diagnose, treat, and help prevent diseases using a system of practice that is based on the
       natural healing capacity of individuals. May use physiological, psychological or
       mechanical methods. May also use natural medicines, prescription or legend drugs,
       foods, herbs, or other natural remedies. Sample job titles include Naturopathic Physician,
       Naturopathic Doctor, Physician, and Doctor of Naturopathic Medicine. (Occupational
       Information Network, 2009)‖

The world of medicine is rapidly changing through the promulgation of regulation, the
passage of legislation and in the daily practice of medicine itself. Naturopathic
physicians, acupuncturists and yes, our conventional partners, the advanced practice
nurses, are a growing force in the transformation of our healthcare system. It is a force
that is driven by consumer experience and increased consumer demand. It is medicine
that demands increased research. There is enormous opportunity in recognizing the
redefinition of how primary care is provided in this country. Enhancing research efforts
on the work of those previously designated as alternative, and now quickly becoming
mainstream, is a precursor to true health care reform.
The AANP stands ready to support NCCAM‘s efforts to enhance infrastructure, expand
research opportunities in the naturopathic field, and advocate for funding of outcomes-
based research initiatives that demonstrate the effectiveness and sustainability of natural
medicine and patient-centered care.

Bodeker, G. (2001). Lessons on Integration from the Developing World‘s Experience.
      British Medical Journal, 322, 164-167. doi:10.1136/bmj.322.7279.164

Bonnefont-Rousselot, D. The Role of Antioxidant Micronutrients in the Prevention of
Diabetic Complications. Treatments in Endocrinology. 3(1): 41-52, 2004.

Bartlett H, Eperjesi F. Nutritional supplementation for type 2 diabetes: a systematic
review. Ophthalmic & Physiological Optics [serial online]. November 2008;28(6):503-

Farvid MS, Jalali M, Siassi F & Hosseini M. Comparison of the effects of vitamins
and/or mineral supplementation on glomerular and tubular dysfunction in type 2 diabetes.
Diabetes Care. 2005 Oct;28(10):2458-64.

Garrow D, Egede LE. National patterns and correlates of complementary and alternative
medicine use in adults with diabetes. J Altern Complement Med. 2006b Nov;12(9):895-

Occupational Information Network. (2009). 29-1199.04 - Naturopathic Physicians.
Retrieved November 11, 2009, from the Occupational Information Network website:

Yeh GY, Eisenberg DM, Davis RB, Phillips RS. Use of complementary and alternative
medicine among persons with diabetes mellitus: results of a national survey. Am J Public
Health. 2002 Oct;92(10):1648-52.